diff --git a/changelog.d/chip-pregnant-coverage-test.fixed.md b/changelog.d/chip-pregnant-coverage-test.fixed.md new file mode 100644 index 00000000000..93102a9f584 --- /dev/null +++ b/changelog.d/chip-pregnant-coverage-test.fixed.md @@ -0,0 +1 @@ +Exclude pregnant people with other health coverage from standard pregnancy CHIP and from the unborn-child (FCEP) option in every state, not only California. diff --git a/policyengine_us/parameters/gov/hhs/chip/disqualifying_health_coverage.yaml b/policyengine_us/parameters/gov/hhs/chip/disqualifying_health_coverage.yaml index 9e38b47fea1..3765fee41b9 100644 --- a/policyengine_us/parameters/gov/hhs/chip/disqualifying_health_coverage.yaml +++ b/policyengine_us/parameters/gov/hhs/chip/disqualifying_health_coverage.yaml @@ -1,4 +1,4 @@ -description: Health coverage sources that disqualify a child from CHIP eligibility. +description: Health coverage sources that disqualify a child or a pregnant person from Children's Health Insurance Program eligibility. values: 0000-01-01: - has_health_coverage_other_than_chip @@ -18,9 +18,13 @@ metadata: period: year label: CHIP disqualifying health coverage sources reference: - - title: 42 CFR § 457.310(b)(2) - Health benefits coverage + - title: 42 CFR § 457.310(b)(2) - No other coverage standard href: https://www.ecfr.gov/current/title-42/section-457.310#p-457.310(b)(2) + - title: 42 CFR § 457.320(a)(7) - Other eligibility standards + href: https://www.ecfr.gov/current/title-42/section-457.320#p-457.320(a)(7) - title: 42 CFR § 457.320(b)(5) - Other eligibility standards href: https://www.ecfr.gov/current/title-42/section-457.320#p-457.320(b)(5) - - title: 45 CFR § 146.113(a)(1) - Excepted benefits + - title: 42 U.S.C. § 1397ll(d)(2)(C) - Targeted low-income pregnant woman + href: https://www.law.cornell.edu/uscode/text/42/1397ll#d_2_C + - title: 45 CFR § 146.113(a)(1) - Creditable coverage href: https://www.ecfr.gov/current/title-45/section-146.113#p-146.113(a)(1) diff --git a/policyengine_us/tests/policy/baseline/gov/hhs/chip/is_chip_eligible_fcep.yaml b/policyengine_us/tests/policy/baseline/gov/hhs/chip/is_chip_eligible_fcep.yaml index 3374ad88144..ca7a2f8b5d9 100644 --- a/policyengine_us/tests/policy/baseline/gov/hhs/chip/is_chip_eligible_fcep.yaml +++ b/policyengine_us/tests/policy/baseline/gov/hhs/chip/is_chip_eligible_fcep.yaml @@ -333,7 +333,10 @@ # California's FCEP population above the Medi-Cal pregnancy limit is the Medi-Cal # Access Program. WIC § 15833 excludes applicants eligible for no-cost Medi-Cal # or Medicare and WIC § 15834 excludes services already covered by private -# coverage, so the CHIP disqualifying coverage list applies in California only. +# coverage. The CHIP disqualifying coverage list applies to FCEP in every +# state and carries these exclusions: 42 CFR 457.310(b)(2) excludes group +# health plan and health insurance coverage, and 42 CFR 457.320(a)(7) lets a +# state also exclude other coverage, such as Medicare. - name: California MCAP applicant without other coverage is eligible period: 2025 input: @@ -448,7 +451,7 @@ is_chip_fcep_eligible_person: true chip_category: PREGNANT_FCEP -- name: The California MCAP insurance exclusion does not reach Texas FCEP +- name: Texas FCEP excludes a pregnant applicant with employer coverage (42 CFR 457.310(b)(2)) period: 2025 input: people: @@ -456,7 +459,8 @@ age: 30 is_pregnant: true is_medicaid_eligible: false - medicaid_income_level: 2 + # Above Texas Medicaid's 203% FPL pregnancy limit, within the 207% FCEP limit. + medicaid_income_level: 2.05 has_esi: true tax_units: tax_unit: @@ -468,7 +472,8 @@ - head state_code: TX output: - is_chip_fcep_eligible_person: true + is_chip_fcep_eligible_person: false + chip_category: NONE # FCEP covers the unborn child regardless of the parent's immigration status. # https://www.medicaid.gov/chip/chip-eligibility-enrollment diff --git a/policyengine_us/tests/policy/baseline/gov/hhs/chip/is_chip_eligible_pregnant.yaml b/policyengine_us/tests/policy/baseline/gov/hhs/chip/is_chip_eligible_pregnant.yaml index be72a71c638..f0cb8c3a086 100644 --- a/policyengine_us/tests/policy/baseline/gov/hhs/chip/is_chip_eligible_pregnant.yaml +++ b/policyengine_us/tests/policy/baseline/gov/hhs/chip/is_chip_eligible_pregnant.yaml @@ -37,3 +37,103 @@ is_chip_fcep_eligible_person: False output: is_chip_eligible_pregnant: False + +- name: Case 5, pregnant woman with employer coverage is not eligible for standard pregnancy CHIP. + period: 2026 + input: + people: + head: + age: 30 + is_pregnant: true + immigration_status: CITIZEN + is_medicaid_eligible: false + medicaid_income_level: 2 + has_esi: true + tax_units: + tax_unit: + members: [head] + households: + household: + members: [head] + state_code: NJ + output: + # New Jersey covers pregnant women up to 205% FPL through CHIP and has no + # FCEP option, but a targeted low-income pregnant woman must be uninsured + # (42 USC 1397ll(d)(2)(C)). + is_chip_eligible_standard_pregnant_person: false + is_chip_fcep_eligible_person: false + is_chip_eligible_pregnant: false + +- name: Case 6, an insured pregnant applicant in a state with both CHIP pregnancy options gets neither option. + period: 2025 + input: + people: + # person1 has employer coverage; person2 is the uninsured control. + person1: + age: 30 + is_pregnant: true + immigration_status: CITIZEN + is_medicaid_eligible: false + medicaid_income_level: 2.3 + has_esi: true + person2: + age: 30 + is_pregnant: true + immigration_status: CITIZEN + is_medicaid_eligible: false + medicaid_income_level: 2.3 + tax_units: + tax_unit1: + members: [person1] + tax_unit2: + members: [person2] + households: + household1: + members: [person1] + state_code: CO + household2: + members: [person2] + state_code: CO + output: + # Colorado offers the standard and FCEP options up to 265% FPL; 230% FPL + # is above its 200% Medicaid pregnancy limit and within both CHIP limits. + is_chip_eligible_standard_pregnant_person: [false, true] + is_chip_fcep_eligible_person: [false, true] + is_chip_eligible_pregnant: [false, true] + chip_category: [NONE, PREGNANT_STANDARD] + +- name: Case 7, other coverage reported through the aggregate input excludes pregnant applicants from both CHIP pregnancy options. + period: 2026 + input: + people: + # person1: New Jersey (standard option only); person2: Texas (FCEP only). + person1: + age: 30 + is_pregnant: true + immigration_status: CITIZEN + is_medicaid_eligible: false + medicaid_income_level: 2 + has_health_coverage_other_than_chip: true + person2: + age: 30 + is_pregnant: true + is_medicaid_eligible: false + medicaid_income_level: 2.05 + has_health_coverage_other_than_chip: true + tax_units: + tax_unit1: + members: [person1] + tax_unit2: + members: [person2] + households: + household1: + members: [person1] + state_code: NJ + household2: + members: [person2] + state_code: TX + output: + is_chip_eligible_standard_pregnant_person: [false, false] + is_chip_fcep_eligible_person: [false, false] + is_chip_eligible_pregnant: [false, false] + chip_category: [NONE, NONE] diff --git a/policyengine_us/tests/policy/baseline/gov/states/ca/dhcs/medi_cal/mixed_households.yaml b/policyengine_us/tests/policy/baseline/gov/states/ca/dhcs/medi_cal/mixed_households.yaml index 606fde918b0..8b5e1c100aa 100644 --- a/policyengine_us/tests/policy/baseline/gov/states/ca/dhcs/medi_cal/mixed_households.yaml +++ b/policyengine_us/tests/policy/baseline/gov/states/ca/dhcs/medi_cal/mixed_households.yaml @@ -1,5 +1,6 @@ -# Mixed-state populations: California's pregnancy counting and MCAP insurance -# exclusion must apply only to California persons within one simulation. +# Mixed-state populations: California's pregnancy counting must apply only to +# California persons, and the CHIP no-other-coverage exclusion must apply per +# person, within one simulation. - name: Case 1, California pregnancy counting remains isolated in a mixed-state population. period: 2025 input: @@ -59,12 +60,12 @@ medicaid_household_size: [5, 5, 5, 3, 4, 3] ca_medicaid_household_pregnancies: [2, 2, 2, 0, 0, 0] -- name: Case 2, California MCAP insurance exclusion is applied per person in a mixed-state population. +- name: Case 2, CHIP no-other-coverage exclusion is applied per person in a mixed-state population. period: 2025 input: people: - # person1: insured Californian; person2: insured Texan control; - # person3: uninsured Californian. + # person1: insured Californian; person2: uninsured Texan above Texas + # Medicaid's 203% FPL pregnancy limit; person3: uninsured Californian. person1: age: 30 is_pregnant: true @@ -74,8 +75,7 @@ person2: age: 30 is_pregnant: true - has_esi: true - medicaid_income_level: 2 + medicaid_income_level: 2.05 is_medicaid_eligible: false person3: age: 30 diff --git a/policyengine_us/variables/gov/hhs/chip/is_chip_eligible_standard_pregnant_person.py b/policyengine_us/variables/gov/hhs/chip/is_chip_eligible_standard_pregnant_person.py index 35bb1bd16ee..f41effb06de 100644 --- a/policyengine_us/variables/gov/hhs/chip/is_chip_eligible_standard_pregnant_person.py +++ b/policyengine_us/variables/gov/hhs/chip/is_chip_eligible_standard_pregnant_person.py @@ -13,6 +13,7 @@ class is_chip_eligible_standard_pregnant_person(Variable): reference = ( "https://www.ssa.gov/OP_Home/ssact/title21/2110.htm", "https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/medicaid-childrens-health-insurance-program-basic-health-program-eligibility-levels", + "https://www.law.cornell.edu/uscode/text/42/1397ll#d_2_C", "https://www.law.cornell.edu/uscode/text/8/1611#a", "https://www.law.cornell.edu/uscode/text/8/1641#b", "https://www.law.cornell.edu/cfr/text/45/155.20", @@ -46,10 +47,18 @@ def formula(person, period, parameters): person, period, parameters, income_limit ) + # A targeted low-income pregnant woman must not be covered under a + # group health plan or health insurance coverage, in the same manner + # as a child (42 USC 1397ll(d)(2)(C) and 1397jj(b)(1)(C)). + has_disqualifying_coverage = person( + "has_chip_disqualifying_health_coverage", period + ) + return ( is_pregnant & state_has_pregnant_chip & immigration_eligible & ~medicaid_eligible & income_eligible + & ~has_disqualifying_coverage ) diff --git a/policyengine_us/variables/gov/hhs/chip/is_chip_fcep_eligible_person.py b/policyengine_us/variables/gov/hhs/chip/is_chip_fcep_eligible_person.py index 99badfcf408..3cf0fb559b5 100644 --- a/policyengine_us/variables/gov/hhs/chip/is_chip_fcep_eligible_person.py +++ b/policyengine_us/variables/gov/hhs/chip/is_chip_fcep_eligible_person.py @@ -22,6 +22,7 @@ class is_chip_fcep_eligible_person(Variable): # 42 CFR 457.10 defines "child" to include the period from conception to # birth, so the unborn child (not the parent) is the CHIP beneficiary. "https://www.law.cornell.edu/cfr/text/42/457.10", + "https://www.ecfr.gov/current/title-42/section-457.310#p-457.310(b)(2)", "https://www.kff.org/affordable-care-act/state-indicator/medicaid-and-chip-income-eligibility-limits-for-pregnant-women-as-a-percent-of-the-federal-poverty-level", # California's FCEP population is the Medi-Cal Access Program. WIC # § 15833 excludes applicants eligible for no-cost Medi-Cal or Medicare @@ -77,17 +78,16 @@ def formula(person, period, parameters): person, period, parameters, income_limit ) - # California's FCEP population above the Medi-Cal pregnancy limit is the - # Medi-Cal Access Program (MCAP). MCAP turns away applicants who are - # eligible for no-cost Medi-Cal or Medicare (WIC § 15833) and applicants - # whose private coverage already covers its services (WIC § 15834), which - # the CHIP disqualifying coverage list captures. The former AIM rule at - # 10 CCR § 2699.200(b)(1)(F)-(G) states the same two exclusions; its - # (b)(1)(G) exception for private plans that omit maternity benefits, or - # carry a maternity-only deductible or copayment above $500, is not - # modeled. - in_california = state_code == StateCode.CA - ca_has_disqualifying_coverage = in_california & person( + # The unborn child is a targeted low-income child, so it must not be + # covered under a group health plan or health insurance coverage + # (42 CFR 457.310(b)(2)). The pregnant person's coverage stands in for + # the unborn child's. California's FCEP population above the Medi-Cal + # pregnancy limit is the Medi-Cal Access Program (MCAP), which states + # the same exclusions (WIC §§ 15833-15834; former AIM rule 10 CCR + # § 2699.200(b)(1)(F)-(G)). MCAP's exception for private plans that + # omit maternity benefits, or carry a maternity-only deductible or + # copayment above $500, is not modeled. + has_disqualifying_coverage = person( "has_chip_disqualifying_health_coverage", period ) @@ -97,5 +97,5 @@ def formula(person, period, parameters): & fcep_geographic_eligible & ~medicaid_eligible & income_eligible - & ~ca_has_disqualifying_coverage + & ~has_disqualifying_coverage )